Except from Contemporary OBGYN Feb 2026
Commentary|Articles|February 19, 2026
Author(s)Barbara Levy, MD
Fact checked by: Benjamin P. Saylor, Tracy Ann Politowicz"Ethical menopause care requires rebuilding trust through transparency, evidence, and shared decision-making," writes Barbara Levy, MD, FACOG, FACS.Barbara Levy, MD, FACOG, FACS
Levy is a board-certified obstetrician/gynecologist and certified menopause provider. She has more than 40 years of experience in direct care, research, and physician training in women’s health care. Levy is currently chief medical officer of Visana Health and chief medical officer of Uroshape, LLC. In addition, she is vice-chair of the American Medical Association’s Current Procedural Terminology Editorial Panel, past chair of the American Medical Association Resource-Based Relative Value Scale Update Committee, and past vice president of health policy at the American College of Obstetricians and Gynecologists for more than 7 years. She has published more than 100 studies and peer-reviewed articles.
Testosterone has emerged as one of the most debated—and misunderstood—interventions in menopause care. In recent years, a growing number of online specialty clinics offering testosterone replacement therapy for women have surfaced, promising more energy, improved mood and focus, enhanced libido, and even muscle gain with little evidence. Although testosterone has demonstrated benefits for a narrow subset of postmenopausal women, the only FDA-regulated therapies on the market today are for men, and evidence does not support its widespread use for many of the outcomes now being marketed. Despite the limited evidence, demand for testosterone therapy among women, both pre-and postmenopausal, continues to accelerate.
The rise in testosterone use among women is not happening in a vacuum. For decades, women have reported feeling dismissed by the traditional health care system when they raise health concerns—particularly related to sexual concerns and changes occurring during midlife. Due in part to gaps in menopause education and training, symptoms such as hot flashes, sleep changes, brain fog, night sweats, and low libido are often framed as a “normal” part of aging, rather than symptoms that can be managed or prevented. Appointments are brief, treatment options are limited, and follow-up is inconsistent or lacking altogether. Feeling frustrated, unheard, and unsupported, many women choose to seek information and solutions on their own from nontraditional spaces.Into that void have stepped online hormone clinics and longevity-focused services offering fast access, definitive answers, and bold promises. Testosterone is often framed not as a targeted therapy with narrow indications, but as a broad solution for restoring youth, productivity, and physical performance. The problem is that this framing frequently ignores basic female physiology and the limited evidence that exists.
There is good evidence that measured testosterone levels in women do not correlate with libido; there is no credible evidence that testosterone at physiologic doses builds muscle mass, improves cognitive function or bone health, or dramatically improves mood and stamina.1 Such effects are seen only when testosterone doses approach the male range—levels that are associated with significant adverse events and potentially irreversible changes in women. In fact, too much testosterone can lead to significant adverse reactions. There seems to be a sweet spot for testosterone therapy.The strongest evidence for testosterone use in women today is narrow and specific: for the treatment of hypoactive sexual desire disorder (HSDD),1 most commonly occurring in women who have undergone surgical menopause with the removal of their ovaries. In these cases, testosterone therapy may have a role. Even still, women require significantly lower testosterone doses than men.
Testosterone is a controlled substance, yet it's being casually marketed to women as a performance enhancer online, often by influencers with no medical oversight. However, no one is taking the time to explain the associated risks of inappropriate dosing.At elevated levels, testosterone can cause irreversible changes, including voice deepening, clitoral enlargement, acne, and hair loss. It may also increase the risk of blood clots and liver dysfunction. Although these risks are well documented in men, they are increasingly concerning in women—particularly when laboratory monitoring is inconsistent or absent.Many companies offering testosterone therapy do not routinely monitor blood counts or liver function, despite clear safety concerns. Testosterone is not benign, and harm may not be reversible. That risk is rarely emphasized.
Responsible testosterone therapy begins with humility, acknowledging what we know, what we don’t, and what the current evidence supports. It requires treating the whole patient, not a single lab value or symptom.Providers looking to better support postmenopausal patients who may benefit should refer to the latest Global Consensus Position Statement on the Use of Testosterone Therapy for Women for recommendations on where to start. The key principles include the following:
Testosterone is FDA-approved for men, not women, and it is not a covered benefit for women. Appropriate dosing for women requires compounding or precise dose adjustment—typically one-tenth of a standard male dose.That raises another critical question: Where is the medication coming from? Is the pharmacy third-party validated? Are dosing and purity independently verified? Not all compounding pharmacies meet the same standards, and “buyer beware” is not a sufficient safety framework for patients.
There is a fine line between empowering women and exploiting their frustration. Ethical menopause care requires rebuilding trust through transparency, evidence, and shared decision-making.Clinicians must be willing to say: “This may help. This may not. Here are the risks. Here is how we will monitor you. And here is when we will stop.”We are starting to see meaningful progress: There are companies actively working toward FDA approval of testosterone therapies specifically designed for women, with appropriately powered trials and female-specific dosing and safety standards. Until then, our responsibility as clinicians is to follow the best available guidance and ensure that any use of testosterone is thoughtful, limited, and grounded in evidence.
References
1. Levy B, Saltiel D, Simon J. Should we consider testosterone therapy in oophorectomized women? J Minim Invasive Gynecol. 2026;33(1):60-64. doi:10.1016/j.jmig.2025.06.018
2. Davis SR, Baber R, Panay N, et al. Global consensus position statement on the use of testosterone therapy for women. J Clin Endocrinol Metab. 2019;104(10):4660-4666. doi:10.1210/jc.2019-01603